Rocks, I was diagnosed at age 52 with a 9 and have survived 8 years. I am now in hospice care with tumors throughout my body but am still working a job and using radiation treatments to try to control some pain. At 82 taking any treatment at all seems overdone. His cancer is very unlikely at that age to have any effect on his end of life and for the best qualilty of life he should just walk away and forget about it. Keep the stress out of his life and I wish you all the best.

I would like you had finished your question as it gives rise to many interpretations. I take your “at this point” as a meaning in regards to your husband’s age of 82. And I agree with 2ndBase’s suggestion that even without any treatment your husband could live many more years and probably die of something else, if he is asymptomatic at this time. Fortunately, prostate cancer is a slow growing type giving many years (over 15 years) of survival to the holders.

Doctors usually recommend radical treatments for older patients if they can foresee positively that benefits are assured from the treatment. In such regards, I do not understand why his doctor have rejected surgery and accepted radiation. Both treatments have risks and side effects some nasty, which would not be preferable to your husband’s last period of his life. Treatments for prostate cancer in Gleason score 9 are very subjective to failure too. Your husband must be fit and in general good health to sustain the treatment.

Hormonal plus IMRT is common to similar cases but not suggested in patients over 75 years old. In older guys it seems proper to recommended palliative type of treatments for PCa such as hormonal therapy. Firmagon alone or in combination with an anti-agonist like Casodex, could handle his case and assure him many years of control, with much lesser risks.

I would recommend you to get a second opinion from an independent oncologist before embarking on the treatment.

Thank you VGama. What I meant about "at this point" was the fact that we are naive about the whole treatment choices.

We are going to see another urologist sometime this week. In fact the original doctor suggested this person who specializes in radiation treatment. Hopefully she will give us a better understanding of what to expect at my husband's age.

Your suggestions are very helpful. At the time of diagnosis you don't know what questions to ask but now with your help and others we will be able to ask more direct questions about treatment.

Thank you VGama. What I meant about "at this point" was the fact that we are naive about the whole treatment choices.

We are going to see another urologist sometime this week. In fact the original doctor suggested this person who specializes in radiation treatment. Hopefully she will give us a better understanding of what to expect at my husband's age.

Your suggestions are very helpful. At the time of diagnosis you don't know what questions to ask but now with your help and others we will be able to ask more direct questions about treatment.

By the way, my husband is not in the best of health. The last 5 months have taken a toll on him. He has fallen and broken his arm and had to have surgery; two days later had to have a pacemaker installed; memory is quite bad some days; and he has diabetes. I think these are some of the reasons the doctor didn't want to do the surgery. I was very hopeful that he would perform the surgery because he is one of the leading doctors in robotic surgery in our area. He told me that he wouldn't even perform the surgery on his own father if he were in my husband's shoes.

Thanks for your comments 2ndBase. My husband and I have been married for 30 years (I am quite a bit younger 55) and still think that he is young enough to fight but I know in my heart it may do more harm...just as you have said.

He started developing dementia (out of the blue) about 4 to 6 months ago so his memory and logic of what is happening with the prostate cancer comes and goes.

I am sorry you have to go through the radiation treatments and still have to work. I hope they are helping with the pain.

I really hope that you get a proper and rightful answer regarding the treatment for your husband. It seems that he is not at all fit to endure 8 weeks of radiation. Moreover, he can do fine with the hormonal protocol alone. Many people is against chemo and mistakenly compare chemotherapy with hormonal therapy, therefore rejecting the treatment, but these are two distinct types with different purposes.
The urologist that has sent you to the radiologist is not to be trusted. He surely has noticed that your husband case should be handled by someone specialised in oncology for older patients.

I am very grateful for your advice and look forward to getting as much information possible through people like you to make an informed decision on my husband's treatment.

From my little understanding on the hormonal therapy it seems as though this might be the best route to take. I need to find out more about the radiation. The original doctor said he needs both - two months of hormonal therapy and then 8 weeks of radiation (also continuing with the hormonal therapy at the same time). I know so little about this cancer that I have no idea why they need to wait if there is a need for radiation. But then again I don't want to be pushed into something that I don't know enough about.

You mention that your husband does not enjoy good health. It is very possible that he will die of something other than prostate cancer,so he may wish to avoid the radical procedures of surgery and IMRT, and enjoy a better quality of life. You might want to discuss with a medical onchologist for prostate cancer.

There are also other less evasive treatment options that you may wish to investigate; there is hifu and cryotherapy. In all honesty I do not know how effective these treatments are for your husbands diagnosis.

Vasco: I don't think there's any basis for your comment that the urologist, who has recommended hormone w/radiation treatment for this 82 year old man, "is not to be be trusted." How do you get there?

The type of radiation treatment to be used has not been specified, but I assume it is IMRT. HT w/IMRT is the commonly recommended treatment for patients w/advanced PCa and has been used successfully w/men of all ages, when the PCa has not yet spread beyond the prostate.

Although dhrocks' husband has early stage dementia and some infirmity associated w/his age, I don't believe that anything has been stated to indicate that he is not fit enough to "endure" radiation treatment. The critical question for me is whether the PCa has migrated beyond the prostate or not and, based on their bone/CT scans, it apparently has not.

I certainly doubt that the urologist & radiologist would recommend radiation treatment if there was any reason to believe it would adversely affect their patient. The radiation oncologist will be able to advise the couple of the risks of radiation for a patient his age and physical condition and there is no reason to believe (based on what has been stated to date) that s/he will not do so "honestly."

If there's any doubt in their minds, dhrocks & her husband should (of course) consult another urologist & radiologist for confirmation regarding the advisability of the HT/radiation recommendation and (from what I gather) that's already what they are planning to do.

BTW, my mother (who is currently 97) received over 20 IMRT radiation treatments to treat a lymphoma in her left chest/arm pit when she was 89. She had no adverse effects as a result of this treatment and I don't think dhrocks' husband necessarily will either.

Swingshiftworker...thanks for your comments. I really didn't know there were different types of radiation therapy until I started reading some of the comments on this board.

My husband's original urologist (who actually said goodbye to us because he said he was a surgeon and not needed any more) said that he would get a sort of radiation that they would first insert gold 'pellets?' strategically around his prostate so the radiation could focus on certain areas. I don't know how that works but it seems to me that they would have to insert a lot of gold in order to get all the areas. My husband had 14 sections biopsied and all but one area had cancer.

I guess I need to read more about the different types of radiation or wait until the new radiation oncologist meets with us on Tuesday to explain a little more. Maybe they will give us a different treatment plan altogether.

I am a little concerned about something I read in the Firmagon pamphlet. Apparently we need to tell our doctor if my husband has/had any problems with sodium or potassium levels. A few months ago my husband's cardiologist had a heck of a time trying to get his sodium level back up...it was quite low. He also had problems with his potassium. I hope there are no problems with Firmagon and salt levels. Maybe I'll do a search on this board to see if anybody else has had a problem regarding this issue.

Again, thank you for sharing about your mother. I hope she is doing well.

SBRT (most notably Cyberknife or CK) and PBT are normally used with men with early stage PCa and are probably not appropriate for your husband. EBRT w/o some form of computer assistance/guidance is seldom used to treat PCa any more because of the much greater risk of damage to adjoining organs/tissues caused by the unfocused application of radiation.

Just be sure to ask your radiation oncologist which form of radiation treatment s/he intends to use and why s/he recommends the use of that method as opposed to the others mentioned above.

You might also want to discuss whether LDR BT (low dose rate brachytherapy), which involves the permanent placement of radioactive seeds in the prostate, or HDR BT (high dose rate brachytherapy), which involves the temporary placement of radioactive implants in the prostate, would be an appropriate alternative to IMRT (or which ever other method of computer assisted/guided EBRT is to be used).

FYI, LDR BT is normally used w/men with early stage PCa, are would probably not be appropriate for your husband. HDR BT is used w/men with later stage PCa but also involves a long hospital stay and multiple visits and may also not be appropriate for an elderly person w/dementia. But, you should hear what your radiation oncologist has to say about it before ruling them out as possible treatments.

I don't know anything about Firmagon and not much about Hormone Therapy (HT) generally but you should obviously discuss w/your urologist whether your husband's sodium/potassium problems negate it's use and, if so, what alternatives are available.

I do know that one of the main complaint about HT is the loss of libido and sexual performance following treatment. That probably isn't a major issue for your 82 year old husband but there is a long list of possible physical side effects that could be problematic for your husband, including: hot flashes, swelling breasts, nausea, gas/indigestion, fatigue, loss of sleep/appetite, flu like symptoms, headaches/dizziness, confusion, drowsiness, dry mouth and vision changes (inability to adjust to different light levels or to perceive color). More seriously, HT can also result in an increased risk of diabetes and heart attack/stroke, increased fracture risk as a result of the loss of bone density, weight gain, decreased muscle mass, increased cholesterol levels, anemia and memory loss.

I got this info from the Prostate Cancer Foundation site at http://www.pcf.org/site/c.leJRIROrEpH/b.5836631/k.3CD9/Side_Effects_of_Hormone_Therapy.htm and from Prostate-Cancer.com at http://www.prostate-cancer.com/hormone-therapy/side-effects/hormonal-side-effects-anti.html.

You should discuss all of these possible side effects from HT w/your urologist, especially given your husband's age and reduced mental capacity.

Sincerely I am surprized by your comment. To accept this surgeon’s directive is like asking a watch maker to repair your shoe.
How could anyone trust an urologist that would disqualify you from his speciality (surgery) and give you a fixed protocol for a treatment of other specialists? It is evident that he knows this patient’s precarious health conditions which are enough indications to suggest various other types of treatments. Recommendations for consultation with specialists of possible treatments are the ethics of practice. Those specialists will then decide on an adequate treatment and protocol whose details will be explained to the patient. That will lead to a final choice and surely to a successful outcome.

Just for being 82 years hold and caught with prostate cancer is an enough argument to be careful on a protocol. The International Society of Geriatric Oncology, whose recommendations include the Practice Guidelines of European Association of Urology, National Comprehensive Cancer Network, and American Urological Association, says that treatments for prostate cancer need to be adapted to patient health status. They have subdivided aged patients into four groups as follows;
1)'Healthy' patients (controlled comorbidity, fully independent in daily living activities, no malnutrition) should receive the same treatment as younger patients;
2)'Vulnerable' patients (reversible impairment) should receive standard treatment after medical intervention;
3)'Frail' patients (irreversible impairment) should receive adapted treatment;
4)Patients who are 'too sick' with 'terminal illness' should receive only symptomatic palliative treatment.

The diagnosis of DH’s husband (Gleason 9, cT3, 13 positive cores out of 14) is also a stage where radiation success is questionable but usually offered to younger healthy men who have at least a 15 year life expectancy. Radiation to localized cases is reasonable but to metastatic cancer, which could be this case (according to diagnosis and nomograms's low percentage) is like trying to treat a wound that may lead to worse conditions.

http://www.goldjournal.net/article/S0090-4295(07)02151-6/abstract
In this site you have a very well described study and recommendations for the sscreening and management of prostate cancer in elderly men: “the Iowa Prostate Cancer Consensus”, but you need to purchase the full text.

With all the respect to your mother, I believe that it may be unfair to compare her successful RT story at 89 with that of PH’s husband. They are different treatments of different dosage, and we survivors have learned, along the years of experience, that in PCa no two cases are equal but similar. What works for one may not work in another.

I insist that PH should seek advice from other independent specialists before committing to the protocol directed by that “famous” Davinci surgeon.

FWIW, I think the urologist's elimination of surgery as an option was well advised (given dh's husband's age and my general belief that the risks of surgery are unnecessary) but I didn't suggest that dh and her husband should unquestionably "accept" the urologist's recommendation for HT w/radiation w/o first seeking additional advice from other physicians (on this point we agree), which I believe they are already planning to do.

I just didn't agree (and still don't) w/your statement that the urologist (who made the original recommendation for HT and followup radiation) "is not to be trusted" based on your apparent conclusion that s/he did not take into account the patient's age and infirmity before recommending radiation treatment. There's no evidence that the urologist did not, in fact, consider the risks of radiation to the patient before making the recommendation. That's where we disagree.

Actually, given dh's husband's medical condition, HT alone (which is what you suggested) may pose a greater risk to him -- in terms of an increased memory loss/dementia and increased risk of diabetes, heart condition and fractures -- all of which he has already) than radiation will which is why I suggested that she also consider surgical castration lieu of HT.

Something else you should ask the urologists/radiation oncologists that you speak to are:

1) Despite all of the possible side effects of HT, would it be advisable to forgo radiation treatment for the reasons that Vasco suggests; ie., will HT w/o radiation be effective w/o exacerbating the your husband's dementia, diabetes, heart condition & risk of fractures?).

2) In lieu of HT, should your husband consider surgical castration instead? The purpose of HT is to reduce/eliminate testosterone production which is linked w/cancer growth and is, in effect, medical castration. Actual physical/surgical castration achieves the same result w/o all of the side effects of HT (other than impotency). If impotency is not an issue and if some of the more serious side effects of HT (including possible additional memory loss and increased fracture and heart attack/diabetes risks) are of greater concern, then perhaps physical castration would be better way to go.

Not suggesting that you choose either of these alternatives. Just that you consider and discuss them w/the specialists you speak with.

I definitely have not made up my mind on any sort of treatment for my husband. I actually panicked and thought that we had to decide immediately what form of treatment he should pursue. You hear the words "cancer; aggressive growth; immediate treatment, etc." so of course not knowing anything we panic.

The original doctor made it sound as though my husband needed to start treatment that day because his cancer is so far advanced. He actually said he would have started the treatment that day but decided he didn't want to step on any toes in regard to the radiation oncologist we will be seeing. This is why I am so happy to hear about all the forms of treatment available...granted maybe not all would be available to my husband but there are many options.

I look forward to hearing another opinion when we see the oncologist on Tuesday.

dh: FWIW, I don't think you need to do anything IMMEDIATELY but you shouldn't unnecessarily delay some sort of treatment decision.

You didn't mention your husband's PSA (which I assume is high), but Gleason 9/Stage T3 is pretty late stage PCa and the cancer has already often spread in other men with a similar diagnosis. Fortunately, your husband's bone/CT scans were negative but that doesn't necessarily mean that the cancer has not actually spread somewhere else in his body already or that it won't spread by the time you make a choice.

BTW, if the cancer has already spread, I still think radiation might be warranted in order to kill the cancer cells concentrated in the prostate but that you would also need to consider hormone therapy or surgical castration in order to prevent the further growth of prostate cancer cells AND chemotherapy to kill cancer cells that have migrated elsewhere. It's an awful scenario that you and your husband have to cope with. Just more you need to discuss w/the oncologists you speak with.

So, IMHO, I think that you really only have a few weeks or months (as opposed to years) to take some kind of action (the longer you wait the greater the risk of the cancer spreading). I know you're already aware of the urgency -- that's why you're here.

Needless to say, you need to read as much and to see as many other specialists as you can, as quickly as you can, so that you can make the best decision possible in the time that you have available.

Hi Swingshift...Just curious about the cancer spreading outside the prostate. What sort of tests show whether or not the cancer has spread. I thought that is what the nuclear bone test and CT scan were suppose to show. Sorry to ask so many questions. Thank you.

Yes, the CT/bone scans are used to try to detect the spread of cancer but they are not perfect in doing this.

So, the cancer could still have spread even though the CT/bone scans do not show anything.
The only way you'd know for sure if it has spread elsewhere is if you can detect another possible cancer location (via the CT/bone scans) and biopsy it, unless the mass is so large that it can't possibly be anything else.

I believe that surgery for an older man with heart disease is not appropriate.

I believe that surgery for a younger man with high gleasons, high volume is not appropriate since the cancer may have escaped the prostate.

I believe that hormone theapy increase risk of heart disease, especially in an older man with heart disease. Also there are other major side effects.

I believe that this man with dementia will not understand why he is castrated.

I beleive that watchful waiting where this man can live the rest of his days in digity, going on with his life with comfort, not suffer the negative effects of major treatments.....there is a very excellent chance that he will die with this disease , not becuase of it.

PS: My Mother who was diagnosed with breast canceer lasr year when ahe was 92 has elected not to have any radiation, and go on with her life. She wants quality of life and has elected not to suffer any treatments. When you have prostate cancer , less is better in a lot of situations.

I couldn't find any writeups regarding continuing medication before treatment. I'm sure I will find out after going to the oncologist on Tuesday but kind of wanted to know ahead of time. My husband is taking Avodart and Tamsulosin. The doctor gave him Avodart about 3 months ago but when his PSA was recently checked it ended up being 11 (although the doctor said it really measures about 22 because of the Avodart). I don't know what that means but I guess it is just another mystery I need to find out about.

I kind of went off track here but wanted to know if my husband eventually stops taking these medications because he will be treated via other methods or do you continue taking these types of medications?

As you can see, I ask the most simple questions because I am still learning. Sorry.

is a new drug. There was a study among patients who have not been diagnosed that showed a reduced amount of men who developed prostate cancer/.

There is current controversy as to whether this drug should be administered to those who already have prostate cancer.

Very recently, information has come to light showing that there are increased deaths due to heart attacks among those who take this drug.

I considered taking the drug,and did some research. It was a hard decision but I chose not to take the drug. This was before the info about increased deaths from heart. I believe that this drug is harmful.

DH
It is wonderful to see you deep engaged in the care of your husband. I understand how stressful you may be since confronted with the words "cancer; aggressive growth; immediate treatment, etc.". I am sorry if my arguments have distracted you in your quest.
You are doing it the right way educating yourself to the problem and researching. Preparing a long list of questions (my advice below) and asking details when in consultations is the best to get to that final decision and peace of mind.

As recommended above by other survivors, your husband’s clinical profile should be taken into consideration. He will need a doctor that will follow-up his case after treatment too.
You could get the opinions from two or three physicians. A medical oncologist specialized in prostate cancer may give you the less biased opinion. It is common to read that urologists and radiologists recommend the treatment of their own field, even though many are well educated in all aspects of Pca. The patient is in charge of the decision and he will be signing an agreement releasing the doctor and the hospital from any responsibility in the outcome of the treatment.

Avodart (dutasteride) and tamsulosin (Flomax) is a combo used to treat benign prostatic hyperplasia (BPH). This is recommended to treat cases of enlarged prostate, particularly when patients have difficulty or pain when urinating.
Avodart is a drug of the 5-ARI class that prevents the conversion of testosterone to dihydrotestosterone (DHT), and it is used as a preventive pill for prostate cancer, but it is controversial as Hopeful comments above.

You should inform the consulting doctor in advance about these drugs too. The oncologist may recommend you a continuation of the drug if symptoms are still prevalent otherwise your husband may stop taking it. Its effect on the treatment of cancer as a sole drug is minimal in the total context of the hormonal therapy.

All treatments and drugs have risks and side effects associated to them. Your husband may need a sort of targeted treatment/medication that needs constant monitoring by a follow-up physician. Many drugs interact with other drugs taken for other illnesses and that must be avoided. Your husband is in a situation indicative that he may need still other medications to handle his other debilities.

You can find a list of questions by googleing this sentence; “questions to ask your doctor about prostate cancer”. Do not be shy about asking questions even if they seem weird to you. You could add these items to your list:
1. How aggressive can we consider his case taking into account his age and other health complications and symptoms?
2. How far advanced is it?
3. Should I get a second opinion for all choices?
4. What are all options?
5. Should I consider do nothing and just monitor any advance?
6. What treatments are best for my husband?
7. Can such treatment lead to other problems or interact with other medications?
8. What can be done to cope with the side effects?
9. Will my husband have to stay in the hospital for treatment? How long?
10. Will treatment keep him from doing certain things and look after himself?
11. How often will he be checked after treatment?
12. Can he go back to normal daily activities after treatment?
13. What experiences have other patients had with similar treatment regimens?
14. Is there any new type of treatment or trials that might be beneficial?
15. What has been your experience with prostate cancer patients similar to his case?
16. Can you recommend any patient support groups in my area?
17. Are there materials I can read about this cancer?

You can call the doctor’s office to request later for specific answers on your first consultation if you have doubts on any opinion.
Here is a post that may help you in deciphering more questions;
http://csn.cancer.org/node/224280

dh: I think that Vasco, Hopeful and I have pretty much covered all of the things that you need to consider before making a final or at least tentative treatment decision for your husband and I don't want to muddy the waters for you any further.

Your husband's medical condition is very complex and becomes more complex as you reveal more about his various medical/mental problems, the medications he's taking and his testing results. Needless to say, you need to reveal ALL of this information to the oncologists/radiologists that you consult in order to make a reasonable decision about what to do (or not do).

As Hopeful points out, it might be best to do nothing at all, except provide care and comfort to your husband in his final years in order to enhance his QUALITY OF LIFE (QOL) for the remainder of his years. If that's not an acceptable alternative to you, you will have to decide whether the risks of treatment are justified by the probable results and their likely effect on your husband's AND your QOL.

No one here can make that decision for you. Unfortunately, that is your responsibility but I am sure that you will do your best to make the best decision possible.

I did a little research regarding the radiation oncologist we will be seeing on Tuesday and found out that the office uses RapidArc technology which treats the tumor 2-8 times quicker than conventional radiation. I can see how my emotions will get in the way of making a decision on my husband's treatment. I assume with the radiation treatments taking only a few minutes the side effects will be less too...or am I living in a fantasy world.

Like everybody said, you don't really know what to expect because there are so many variables.

The RapidArc technology isn't talked about much on this board...is it new or just not as good as other methods?

A quick Google search revealed that RapidArc is the proprietary name of a type of IGRT (Image Guided Radiation Therapy), which is similar to IMRT and 3D Conformal Radiation Therapy.

If you haven't seen it already, you should read MrsPJD's detailed history of her and her husband's decision to use HT, HDR BT and IMRT in combination to treat PJD's Stage T3 Pca. It was posted on 9/2/11 in the "3 Weeks After Testing Positive" thread.

DH
I'm so amazed to read your post. Your husband's diagnosis and age is the same as my husband's...so we have a similar situation to face. There is so much information on this thread to absorb, and I haven't read it all yet.

I will read everything tonight and post tomorrow to share the treatment information we have chosen.

Although our husbands have similarities...we are all different, and ours is a bit complicated. I will try to share anything that we may have in common.

My husband (John) was diagnosed last fall with Gleason score of 8 (4+4). Stage 3 or 4.
PSA at the time, 13.2
Bone scan was clear
Lymph nodes were then found not to be involved. It was a second cancer - Hodgkin's Lymphoma.

He began chemotherapy for Hodgkin's at Thanksgiving, and is now in remission.

Now we are facing decisions about the Prostate treatment.
He began Firmagon monthly injections last fall. (PSA has reduced to 0.1)
After two months we decided to switch to Lupron (every three months), and the last Lupron treatment on August 23 was for six months!

John has had NO discernible side effects from these injections... with the possible exception of tiredness, but that also might just be expected for his age (80).

His Urologist, during the August visit, is pushing for radiation treatments. She said it would add ten years to his life...ya, sure! In October John has a follow up visit with his Chemo doctor, whom we respect. We will discuss this topic and (possibly) consider having a consultation with the Radiology physician.

However, our current decision is to continue 'watchful waiting'. We wish to enjoy the quality of life remaining. The hormone treatment will sustain him for a few more years. He is otherwise healthy.

I share with you the difficulty of being a caregiver...but you've got twenty years on me. Please let me know about your appointment tomorrow.

The content on this site is for informational purposes only. It is not a substitute for professional medical advice. Do not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.